Dr Andrew Kyoong    Respiratory & Sleep Physician | Dr Chong Weng Ong   Respiratory & Sleep Physician
PLEASE REMEMBER: THIS REFERRAL MUST BE PRESENTED AT YOUR APPOINTMENT
T: 03 9912  9001        F: 03 9510 3299      E: reception.melbourne@sleepcrs.net.au

_Patient _Name: | <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Address: | <<Patient Demographics:Address>>
Phone: | Home:<<Patient Demographics:Phone (Home)>>  Mobile:<<Patient Demographics:Phone (Mobile)>>
Date of Birth: | <<Patient Demographics:DOB>>
Health Identifier: | <<Patient Demographics:IHI>>
Medicare No: | <<Patient Demographics:Medicare Number>>
Health Insurance Cover: | <<Patient Demographics:Health Insurance>>
   
RESPIRATORY FUNCTION TESTS:
<<Respiratory Test 1>> | <<Respiratory Test 2>>
<<Respiratory Test 3>> |

SLEEP SERVICES:
<<Sleep Services 1>> | <<Sleep Services 2>>
<<Sleep Services 3>> | <<Sleep Services 4>>
<<Sleep Services 5>> |
(Sleep study will be either Laboratory or Comprehensive Home Based Sleep Study based on patient's clinical history)
CONSULTATION:
<< Consultation Type Required>>	
CLINICAL DETAILS: <<Clinical Details >>  
Additional Details: <<Additional Clinical Details>> 
REFERRING DOCTOR: <<Doctor:Name>>  Provider No: <<Doctor:Provider Number>>  
  <<Practice:Name>>
<<Doctor:Address Line 1>> <<Doctor:Address Line 2>>, <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>       Tel:<<Practice:Phone>>

Referring Doctor's Signature:.................................    Date: <<Miscellaneous:Date>>

Copy of Report to: <<Copy of Report To>> 

e-referral ID Medical Objects: PC60000005W or Healthlink: hollspec

LOCATIONS |
ARMADALE | Ground Floor, Suite 2  615 Dandenong Rd, Vic 3143
GLEN WAVERLEY | Suite 1, 260 Springvale Rd, Vic 3150
KEW EAST | 215 Kilby Rd, Vic 3102
Your doctor has recommended that you use CRS. You may use another provider but please discuss this with your doctor first.  v1.0/2018